MEDICARE: HERITAGE CARE CENTER OF BERKELEY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750378584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE CARE CENTER OF BERKELEY, LLC

Provider Business Mailing Address
First Line	:	1869 CRAIG PARK CT
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-4122
Country	:	US
Telephone Number	:	314-543-3800
Fax Number	:	314-543-3880

Provider Business Practice Location Address
First Line	:	4401 N HANLEY RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63134-2710
Country	:	US
Telephone Number	:	314-521-7471
Fax Number	:	314-521-4845

Authorized Official
Title or Position	:	FINANCE
Name	:	ASHWIN DUNDOO
Credential	:
Telephone Number	:	314-543-3800

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	05/30/2013

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